Ascites Treatment & Management

Sodium restriction (20-30 mEq/d) and diuretic therapy constitute the standard medical management for ascites and are effective in approximately 95% of patients. Note the following:

• Water restriction is used only if persistent hyponatremia is present (see Diet, below).

• More recent research has focused on the treatment of refractory ascites with aquaretics—vasopressin V2-receptor antagonists that promote excretion of electrolyte-free water and thus might be beneficial in patients with ascites and hyponatremia. ^[9] Although study results have been promising, ^[10] aquaretics still await approval by the Food and Drug Administration (FDA).

• In a multicenter study that assessed the safety and efficacy of an automated pump system for the treatment of refractory ascites in 40 patients at 9 centers, Bellot et al reported the automated pump was an efficacious tool to remove ascites from the peritoneal cavity to the bladder. ^[11] During the 6-month follow-up period, 90% of the ascites was removed with the pump system; there was also a significant reduction in the monthly median number of large volume paracentesis as well as a reduction in the number of cirrhosis-related adverse events. ^[11]

• Therapeutic paracentesis may be performed in patients who require rapid symptomatic relief for refractory or tense ascites. When small volumes of ascitic fluid are removed, saline alone is an effective plasma expander. ^[12] The removal of 5 L of fluid or more is considered large-volume paracentesis. ^[1] Total paracentesis, that is, removal of all ascites (even >20 L), can usually be performed safely.

• Supplementing 5 g of albumin per each liter over 5 L of ascitic fluid removed decreases complications of paracentesis, such as electrolyte imbalances and increases in serum creatinine levels secondary to large shifts of intravascular volume. Note: The AASLD indicates that postparacentesis albumin infusion may not be necessary for a single paracentesis of less than 4 to 5 L ((class I, level C recommendation); however, for large-volume paracenteses, an albumin infusion of 6-8 g per liter of fluid removed appears to improve survival and is recommended (class IIa, level C recommendation). ^[8]

• To avoid exposing patients to blood products, the use of terlipressin (eg, 1 mg every 4 hours for 48 hours) rather than albumin has been proposed for prevention of circulatory dysfunction after large-volume paracentesis. Initial studies suggest that terlipressin is as effective as albumin for this purpose. ^{[13, 14]}

• Repeated therapeutic paracentesis can be used to treat refractory ascites (class I, level C recommendation). ^[8] For palliative care in patients with advanced cancer, an alternative to serial paracenteses is placement of an indwelling peritoneal catheter; ascitic fluid can then be removed by continuous drainage ^[15] or intermittent drainage with a proprietary system utilizing vacuum bottles, which can be performed in the patient’s home. ^[16] Preservation of good nutrition status is important. ^[17]

• The transjugular intrahepatic portosystemic shunt (TIPS) is an interventional radiologic technique that reduces portal pressure and may be the most effective treatment for patients with diuretic-resistant ascites. In the procedure, which is performed with the patient under conscious sedation or general anesthesia, an interventional radiologist places a stent percutaneously from the right jugular vein into the hepatic vein, thereby creating a connection between the portal and systemic circulations. TIPS is gradually becoming the standard of care in patients with diuretic-refractory ascites.

In a systematic review and meta-analysis of 10 trials comprising 462 patients with cirrhotic ascites, Guo et al reported that midodrine, a vasopressor, used as a novel threapy for the ascites caused by cirrhosis did not improve survival but potentially improved response rates and reduced plasma renin activity. ^[18] However, when midodrine was used as an alternative to albumin in large-volume paracentesis, the mortality was higher for those receiving midodrine than for those receiving albumin;midodrine and albumin had a similar association with the development paracentesis-induced circulatory dysfunction. ^[18]

Conservative management appears to be the treatment of choice for patients with chylous ascites. ^[3]

Patients can actually be maintained free of ascites if sodium intake is limited to 10 mmol/d. However, this is not practical outside a metabolic ward.

Twenty-four–hour urinary sodium measurements are useful in patients with ascites related to portal hypertension in order to assess the degree of sodium avidity, monitor the response to diuretics, and assess compliance with diet.

For grade 3 or 4 ascites, therapeutic paracentesis may be necessary intermittently.

The peritoneovenous shunt is an alternative for patients with medically intractable ascites. This is a megalymphatic shunt that returns the ascitic fluid to the central venous system. Beneficial effects of these shunts include increased cardiac output, renal blood flow, glomerular filtration rate, urinary volume, and sodium excretion and decreased plasma renin activity and plasma aldosterone concentration. Although it has largely been supplanted by TIPS, peritoneovenous shunting has been shown to improve short-term survival (compared with paracentesis) in cancer patients with refractory malignant ascites. ^[19] The AASLD suggests considering peritoneovenous shunting for patients with refractory ascites who are not candidates for paracentesis, transplant, or TIPS (class I, level A recommendation). ^[8]

Transjugular intrahepatic portosystemic shunt (TIPS).

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The AASLD recommends that patients with cirrhosis and ascites be considered for liver transplantation (class I, level B recommendation). ^[8]

Consultation with a gastrointestinal specialist and/or hepatologist should be considered for all patients with ascites, particularly if the ascites is refractory to medical treatment.

Sodium restriction of 500 mg/d (22 mmol/d) is feasible in a hospital setting; however, it is unrealistic in most outpatient settings. A more appropriate sodium restriction is 2000 mg/d (88 mmol). Indiscriminate fluid restriction is inappropriate. Fluids need not be restricted unless the serum sodium level drops below 120 mmol/L.

The best method of assessing the effectiveness of diuretic therapy is by monitoring body weight and urinary sodium levels.

In general, the goal of diuretic treatment of ascites should be to achieve a weight loss of 300-500 g/d in patients without edema and 800-1000 g/d in patients with edema.

Once ascites has disappeared, diuretic treatment should be adjusted to maintain the patient free of ascites.